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Death and readmissions after hospital discharge during the December holiday period: cohort study

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Death is deadly, but hope is heady. So although war and sickness spoil living and loving, dreams foil death by toiling for peace and health. To quote John Donne, "Death be not proud, though some have called thee mighty and dreadful, for thou art not so".

I read with interest this large and robust cohort study on a challenging topic relevant to both clinical practice and health policy. This paper could be cited in medical and mainstream media and may add fuel to healthcare management and political fires in some regions regarding staffing of hospitals during the December holiday season. The primary outcome was death or readmission, defined as a visit to an emergency department or urgent rehospitalisation, within 30 days. The paper highlights that patients discharged over the December holiday period are less likely to have scheduled follow up and more likely to attend the emergency department, both of which are undesirable and unsatisfactory outcomes for patients and hospitals and the results as presented supporting this are meaningful. However, the authors' selection, presentation of the composite end-point and their emphasis on an increased rate of death stated in the abstract,conclusion and frequently repeated throughout the text could be challenged.
Composite end-points, if not appropriately selected, are both confusing and a source of misleading information and this has been highlighted previously in the BMJ in the context of clinical trials. [1] It can equally be applied to cohort studies. Furthermore, when the outcomes involve vastly different degrees of importance to patients, clinicians or even administrators the choice of outcomes must be questioned. If an outcome is an outcome is an outcome, then a trip to the emergency department is not a readmission is not a death.

I have read the full paper and the supplementary material. The 30 day deaths rate was 1.5% in each group which is an unadjusted risk difference of 0%. In subgroups often associated with unplanned readmissions such as patients with congestive cardiac failure and COPD there also was no difference in death rate, in fact a few less deaths were observed in COPD patients discharged over the holiday season (2.2 v 2.8%, appendix table 7). The difference in 30 day rehospitalisation rate for the entire population was 0.4% (11.8 v 11.4%).

Emphasising death in the composite end-points observed could detract from the authenticity and usefulness of otherwise important results demonstrated by the authors. To paraphrase from the conclusion on unwanted gifts, unwanted results, perhaps inconvenient to the narrative, should not be buried in the appendices.

Lapointe-Shaw et al. (1) reported that patients discharged from hospital during the December holiday period are at higher risk of death or readmission within 30 days. They explain this increased risk by reduced access to care and to physicians.

What’s the solution? To increase the duration of hospitalisation until the end of holidays? No holidays for health professionals in December?

Complications occur more frequently in holidays but also in the second part of the night and at weekends. However, if a complication occurs and there is a complaint, the judges will not take into account the holiday factors.

I think that in our practice in developed countries, there are other factors. Indeed, when the patient is discharged from hospital, follow-up by nurses and GPs is usually performed.

For me the real problem is that in some cases, even in patients who are followed up outside hospital, complications and sometimes death occur without any medical alert. For example, after a hysterectomy or a caesarean section, patients have a daily injection of anticoagulants by nurses. Despite the daily presence of a health professional, we deplore in rare cases serious complications like thromboembolism, severe pelvic infection or death without any alarm or diagnosis of a complication before the event. There was no diagnosis outside the hospital of any clinical signs that could evolve into a dramatic situation and jeopardize the patient’s life. The lack of recognising symptoms led to underestimation of the situation and patents were not addressed to the hospital. In such a situation the patient could die. It is due not only to a problem of reduced access to health care but also a lack of knowledge (3) and training of some nurses and health professionals to detect serious situations, like pain, hemorrhage infections and other signs leading to complications or death (3).

Finally, the reduced access to care during holidays is a reality. However, the health professional that follows up patients after hospital discharge should be trained to recognize emergency situations that must be readdressed to the hospital.